jeffcubos.com » Lumbar Spine / Core

Looking at the Literature: MSK Myths

jcubos — Tue, 20 Dec 2011 05:44:02 +0000

Title: Musculoskeletal Myths

Author: C. Liebenson

Journal: Journal of Bodywork and Movement Therapies

Date: December 2011

Summary:

A must read for all professionals in the health care and fitness industries. In this review, Craig Liebenson not only utilizes the current state of the literature to debunk 10 widely common myths in low back health, but also provides us with evidence-informed alternatives and explanations. From the role of diagnostic imaging in low back pain to spine stability and pain science, Liebenson does an eloquent job in stressing the importance of a science-based approach to patient management and the value in active care. Some of the myths discussed are: “the cause of musculoskeletal pain can be found on an x-ray or MRI”; “let pain be your guide”; “the deep intrinsic muscles…are the keys to stability”; and “we should breathe out with exertion-right?”.
In addition to the exposure of these myths, Liebenson also introduces the reader to a new paradigm of care that is grounded in the functional assessment. It has been highly stressed that we, as clinicians, should be focusing more on the source – rather than the site – of pain, and Liebenson provides us with a clear rationale for this approach. He further provides specific evidence via regional interdependence of this paradigm shift.

“This new paradigm requires a reevaluation of a number of current tenets of care. If this happens a more patient-centered approach which is designed to help patients safely return to activities which are important to them will result”

Liebenson, C. (2011). Musculoskeletal Myths. Journal of Bodywork and Movement Therapies. doi:10.1016/j.jbmt.2011.11.003.

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Understanding McKenzie MDT – “A”: The Lumbar Spine

jcubos — Mon, 12 Dec 2011 21:08:31 +0000

Having studied under Craig Liebenson for quite some time, I have developed a better appreciation for the McKenzie Mechanical Diagnosis and Therapy system. Seeing Dr. Liebenson relentlessly “audit” his patients, and understanding that this audit forms the foundation of McKenzie principles, the reassessment has become a cornerstone in the management of my patients.

As such, and to gain a better understanding of this system, I decided to host McKenzie “A” – The Lumbar Spine at my clinic.

It truly is more than centralization

Apparently, this was the first course held in Canada that combined physical therapists and chiropractors as delegates. To me this was significant as I have always held the belief that who you are is more important than what you are.

Now the key take away from this course was perhaps the first statement made by our instructor, Audrey Long.

“It’s about applying the right thing to the right patient”

To me, the above statement means conducting a thorough and accurate assessment, applying the appropriate management strategy, and reassessing to confirm the effectiveness of that strategy. So it was clear to me that McKenzie MDT was more of an assessment method than a treatment method.

The second principle learned from this course was another “Craig-ism”…the importance of self-care. That it is very important that we first utilize an active, hands off, approach in order to allow the patient to learn about the treatment experience. Taking this approach promotes independence and a better understanding (by the patient) that they have the power to “make themselves feel better”.

Now it is still considered manual therapy, better decision making is just employed to determine when and when not to put one’s hands on the patient.

One important key to a thorough assessment is the patient history, and understanding why they got there in the first place. Quite often it is what they didn’t do, rather than what they did, but it is also likely related to their tendencies. Do they sit all day? Do they stand all day? Are they constantly bending? Are they constantly twisting? Or…do they have faulty movement patterns?

Maybe it is simply a matter of facebooking and skinny jeans?

In all seriousness, while the philosophy that surrounds this method of treatment lies in the clinical audit process, there is no question that most therapists equate McKenzie MDT to discogenic pathologies. And for good reason.

However, quite often such pathologies, especially of the acute variety, present with pain induced sympathetic overload and/or faulty core function secondary to high threshold strategies.

For the latter, often the patient presents with antalgia and obvious signs including, but not limited to, guarding, sweating, fear of movement, etc. In such cases, for me to put them through repeated movement testing from the get go, may not be the best approach. Some therapists will often use ice, IFC and e-stim, but for me, I would rather unwind the system that’s on lockdown. And by that I mean, decreasing the threat.

Tap into their PNS and the guards will go away.

Patrick Ward recently wrote about the Parasympathetic Nervous System. For me, the methods I often use are crocodile breathing, gentle perturbations rib cage and hip mobilizations, soft bracing as per Stu McGill, reactive neuromuscular training and reflex stimulation…all dependent on patient presentation. And ALL with appropriate (read reassuring) communication.

I will also groove proper hip hinging and thoracic uprighting. But following that, and when appropriate, I would then implement centralization methods. Likely on the first visit but always with respiratory control.

Ultimately though, my goal aside from the above history, would be to understand why the individual mechanically sustained the injury to begin with. And this is where the SFMA fits in…to respect the high threshold strategy. This is also where Stuart McGill’s strategies come in. Sometimes prior to calling off security, and sometimes after. But definitely always.

I admit that I am still having difficulties with my understanding of McKenzie methods. Not only because this method “tissue-fies” many pain presentations, but also because I believe there may be more appropriate ways to assess and “treat” with repeated movement in very acute conditions. Our instructor suggested that, ”we should stick with McKenzie and not mix systems (i.e. stability and muscle imbalances)” and to me, this may not be the best approach. I truly believe that the patient should take priority over the method and therefore, I will continue to do what I feel is most appropriate.

That said, I still have a lot of learning to do but thankfully the manual is close to 200 pages, so I’ll certainly be busy studying over the holidays.

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Low Back Pain – A Contemporary Healthcare Crisis

jcubos — Sat, 10 Dec 2011 05:15:37 +0000

As a health care practitioner who “sees” back pain on a daily basis, I thought it would be important to bring this important article series to your attention.

This series was written by my friend and colleague, Dr. Shawn Thistle of Research Review Service.

If you are a health care practitioner, strength coach, or individual who works with this population/demographic, I highly suggest you take the time to read.

Here’s the link.

Low Back Pain – A Contemporary Healthcare Crisis

The Role of Diagnostic Imaging for Low Back Pain R. Chou, A. Qaseem, DK. Owens et al. (2011). Diagnostic...
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Controversy or Responsibility

jcubos — Sun, 04 Dec 2011 06:12:10 +0000

The internet is powerful.

Sometimes good. Sometimes bad. But powerful.

Earlier this week I read a blog post, that in some minds was controversial. In my mind, irresponsible.

Here’s the link: Corrective Exercise for Disc Herniations

While suggestions were made to seek care from a health care practitioner, clearly the intent was to treat such conditions. Treatment can come in many forms, from medications to manual therapy to cognitive coaching. In this case, treatment was exercise. One problem with this is that each and every patient presentation is context dependent. And while this is so, there are certain rules that must be respected when it comes to discogenic presentations.

On the other hand, I also read another blog post this week from an educated and responsible non-therapist. Again context is important but in my opinion, this post was much more contemporary, responsible and educational.

Here’s the link: How to Lift with a Herniated Disc

I hope you see the difference and understand that my main message is that if you intend to educate, not only do you need to do your homework, but more importantly you need to accept responsibility.

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McKenzie Method in Mechanical Diagnosis and Therapy – Part A

jcubos — Tue, 01 Nov 2011 18:53:20 +0000

December 2-4, 2011

Spruce Grove, Alberta

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Part A: The Lumbar Spine

Course Description
This four day (28 hrs) course presents the theorectical aspects and concepts of the McKenzie Method in Mechanical Diagnosis and Therapy, as applied in the examination and treatment of patients with complaints of low back and related referred pain. Through lectures and patient demonstrations, the derangement, dysfunction and postural syndromes are described in detail and appropriate treatment plans are outlined with emphasis on the use of patient self-treatment procedures. The clinical efficacy and limitations of the McKenzie approach as applied to the lumbar spine, are illustrated by follow-up patient demonstrations.

Course Goals
Following attentive participation and completion, this course will provide participants with the introductory knowledge, basic skills and abilities to begin to:

Appropriately apply the McKenzie Method of Mechanical Diagnosis and Therapy to patients with lumbar spine problems.
Distinguish between the McKenzie syndromes (derangement, dysfunction, postural) and other spinal conditions and provide appropriate management regimens for each of the McKenzie syndromes.
Identify when the application of external forces is required for the resolution of symptoms using McKenzie’s concept of progression of forces.
Assist patients to design and apply the therapeutic processes on their own to achieve management goals.

Click here for more information.

Click here to register.

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Improving core function from the inside out…but it’s not what you think!

jcubos — Mon, 03 Oct 2011 00:22:22 +0000

I’m strongly considering the thought of bringing in both a naturopath and psychologist into the clinic.

In speaking with an osteopath over the weekend, he really got me thinking about core function. We were discussing the current state of the literature and he pointed out that while the research to date are all fine and dandy, there doesn’t seem to be anyone who’s utilized truly healthy individuals that are free from visceral/organ dysfunction. That’s not to say that the subjects who have participated in McGill’s, Hodges’ and others’ studies are not “healthy”, but it seems as though such particular issues have yet to be addressed.

The rationale behind his insight was the fact that our current society consumes far too much *you know what* to ensure that our abdominal organs are functioning optimally. And as a result, many in today’s society suffer from certain inflammatory conditions that may have negative effects on proper core muscle function.

Take for example the Transversus Abdominis. This is one of the deep muscles of our core and through research, has been shown to have a delay in firing in those with chronic low back pain. Now if our intestines and organs are “inflamed”, the possibility of influencing muscle function surely exists. Think about the length-tension relationship and the ability to generate force. So perhaps the T.A. may be dysfunctional in those with chronic low back pain due to the above.

On a different level, think about the role stress plays on organ function? Aside from the negative cognitive consequences it may have on those with chronic pain, what about those with chronic low back pain?

So where do we go from here? We were in mutual agreement that we should probably start with inclusion and exclusion criteria. Don’t get me wrong, I know that this is not an easy task but perhaps we may be able to get an even better idea of what truly goes on in the core with more optimal subject population.

But in the meantime, if we’re working with people suffering from faulty core function, perhaps it may be prudent to spend even more time considering the role of stress and common allergens.

And that’s why I think I need to strongly consider the assistance of a naturopath and a psychologist.

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Craig Liebenson’s DVDs

jcubos — Sun, 02 Oct 2011 02:06:29 +0000

Progressions, progressions, progressions.

If you have had the pleasure of attending one of Dr. Liebenson’s seminars, you’ll know first hand that he utilizes a large battery of exercises to rehabilitate a patient with functional pathology. While many of us attendees wished we were looking at the patient through his own lens, often we’ll ask ourselves “how the heck did he know that that exercise was the key link”?

Well in my opinion and aside from his extensive experience, there are two primary reasons why Craig can pull a specific exercise out from the score keeper’s room behind the Green Monster (let alone left field) and instantaneously help a patient improve their dysfunction. The first being the Clinical Audit Process and the second being a continuum of exercise progressions.

In the sport performance world, exercise progressions are to athletic development as I am to continuing education. And frankly, I don’t think the rehab world should be any different. Now I’m not talking about 8 repetitions this week and 10 repetitions next, but more so utilizing a continuum of exercises with similar objectives but with varying difficulties for the purpose of matching the right exercise to the said patient.

For those of you familiar with the FMS, you will know that Gray and Lee have their priorities and progressions. Pavel Kolar and DNS is not different and while I myself have never taken the RKC, I am quite confident that Pavel and his army are no different.

So in the rehab realm, how do we choose the most appropriate exercise for our patients? Well recently, Dr. Liebenson released his new 3-DVD set that answers just that. But as always, we must first start with a functional evaluation. Because without this, as Dr. Liebenson says, “any training flexibility, stability, or performance training is no more than dumb luck”. For more on functional evaluations, I highly suggest you attend one of his seminars, as well as that of the SFMA and Stuart McGill.

So with these dvds, it is important to understand that it is the principles upon which corresponding exercises are chosen. Remember, it’s not about the tools but the principles behind them.

Core Stability Training

For those of you in the rehab world, you probably already use several of these exercises already. Some of you may use them as your “core” exercises and others may simply use them to troubleshoot a specific patient. What some people fail to realize, however, is that Dr. Liebenson has been around since the invention of such exercises. Take McGill’s “big 3″ for example. Did you know that Stu and Craig have worked closely together for many years? To me, if I’m using specific exercises for my patients, I want to make sure that they are being performed correctly. And with this particular dvd (as well as the other two), Dr. Liebenson does an excellent job instructing each exercise and providing the most effective cues during their performance.

Flexibility, Yoga Training, and Ergonomic Advice

You probably are aware that I recently provided a lecture on “respiratory control” for the Muscle Imabalances Revealed series. Well let me tell you that much of what I know on this topic came from Dr. Liebenson himself. In this dvd, he does an excellent job explaining both the importance and the mechanics of optimal respiration and also demonstrates how both to assess breathing and integrate it with exercise. He also demonstrates several tools to send your patients home with in order to perform their normal activities of daily living in an unloaded manner. Because to me, what your patients do during the 23 hours of the day outside your clinic is probably more important than what they do during the one hour within your clinic.

Functional Performance Training

With the emerging rehab renaissance of integrating functional training and sport performance exercises in the rehabilitation world, many rehabilitation professionals may still be in the wide-eyed state when it comes to working with athletes. Since Dr. Liebenson rubs shoulders with some of the most successful strength coaches today, he certainly is no stranger to such methods of training. In this dvd, he introduces perhaps the most relevant and realistic exercises that you may employ within your clinic to help you seamlessly hand your patient off to the strength coach. A must if you want to keep up with the Jones’ in the sport medicine and rehabilitation world.

Overall, these dvds set themselves apart from many others not only because of the creator behind the discs, but also because of their professional quality. Utilizing custom-created images as well as “live” dialogues, Dr. Liebenson takes the time to explain with detail the purpose behind each exercise series. Certainly many more exercises will be invented but like I said, the principles behind the process are what’s most important. And it is these principles that will stick around in our industry for many years to come.

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The Crunch Debate Continues!

jcubos — Fri, 23 Sep 2011 02:54:27 +0000

For those of you that have been hiding under a rug in the last few months, let me direct you to a recently published article in the Strength and Conditioning Journal. This paper was written by Bret Contreras and Brad Schoenfeld and really looked into the literature on the topic of crunches.

“To Crunch or Not to Crunch”

No if you spend any time on the internet, you’ll know that this paper has been widely discussed. From Mike Robertson’s forum to T-Nation to Strength Coach.

Now I recently shared my two cents on core training through a webinar on Strength and Conditioning Webinars and Sports Rehab Expert but the above specifically discussed crunches.

Naturally, Dr. Stuart McGill recently had a few words to say so may I direct you to Dr. Snell’s awesome site, myrehabexercise.com. And while you’re at it, make sure you sign up for the site and use the referral code - promo46034. Click here for more information why.

Please note that the strength coach, sports rehab expert and strength and conditioning webinars links are of the affiliate variety.

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Looking at the Literature: Spine Stability and the Balancing Stick

jcubos — Thu, 01 Sep 2011 22:21:04 +0000

Study Title: Spine stability: Lessons from a balancing stick

Authors: NP. Reeves, KS, Narendra & J. Cholewicki

Journal: Clinical Biomechanics

Date: 2011

Summary:

Reeves does it again! This paper here was a continuation of his “Spine Stability” series of papers and although not an actual study, was an excellent “lecture” piece. Coming off of his Six Blind Men & the Elephant paper where he looked at the role and importance of robustness (or variability) for both static and dynamic stability , Reeves uses a simple object, a stick, to provide us with a conceptual, but comprehensive lesson in spinal stability. In this paper, he walks us through five different “lessons”, all pertaining to a stick (or two) being balanced, to help us look further into the information necessary to stabilize the spine, noise in control and spine performance, spine evolution for stabilization and efficient control, control delays and spine performance, and the role of goals for spine control. All pertaining to feedback control.
His first experiment examined the role tracking plays in stability through positive and negative feedback. It was discovered that inorder to balance a stick in the hand effectively, one must possess both position and velocity related feedback. The lesson from this was that the central nervous system monitors both position and velocity during spinal movement for each degree of freedom (rotation and translation about each axis) it possesses. Its significance? That muscle spindles, especially of the deep musculature, play an important role by measuring both muscle length and rate of change for spinal stability.
His second experiment examined tracking into more detail by looking at precision. Using similar concepts to the image above, he placed a weight on the top of the stick for one trial and down at the bottom for the next to understand angular displacement and velocity. It was realized that balancing the stick with a weight at the bottom created a larger “gain” (or necessary force) to maintain equilibrium and as such, the lesson was learned that impairments in tracking the spine will impair control and may lead to non-optimal recruitment patterns. Therefore, the relevance of this was that not only is position-related feedback important but also velocity related feedback for spinal control.
The third experiment looked into controllability and observability. Using two different trials of stick balancing (one with two sticks in series – on top of each other – and the other with two sticks in parallel – beside each other), it was revealed that multiple masses will have different movement characteristics. The lesson from this experiment was that independent control of the various spine segments through its physical make up and neural recruitment may be important for feedback control and subsequent stability, as well as metabolic efficiency.
His fourth experiment examined delays in feedback control. By utilizing multiple trials with various stick lengths, it was revealed that shorter sticks make balancing more difficult due to an increase in size and rate of oscillation. He attributed this to delays in feedback control. The relevance? In rapid dynamic environments, feedback control may negatively influence spine control, especially in the low back pain population.
The final experiment was more of an observation looking at various control strategies. Realistically, there are many different ways to balance a stick and so for any given task, there will likely be an infinite number of possible feedback gains to provide stability. Ultimately, the objective should be to respect the goals of the system (or the person) whether it be for maximizing performance or minimizing costs. The takeaway from here is that the central nervous system should learn the dynamics of the spine system and that neuromuscular retraining may be valuable to help “reset control to a more desirable strategy”.

We must remember, however, that this was a “lecture” piece rather than an actual clinical trial or review. The principles in this paper are quite sound but as always, more rigorous research in these topics must be performed especially with humans as subjects.

Reeves, NP. et al. (2011). Spine stability: Lessons from a balancing stick. Clinical Biomechanics, vol 26; 325 – 330

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Looking at the Literature: Postoperative Gluteus Medius Rehab with Consideration of the Iliopsoas

jcubos — Fri, 19 Aug 2011 05:52:57 +0000

Study Title: Rehabilitation Exercise Progression for the Gluteus Medius Muscle With Consideration for Iliopsoas Tendinitis

Authors: MJ. Philippon, MJ. Decker, E. Giphart, MR. Tory, MS. Wahoff & RF. LaPrade

Journal: American Journal of Sports Medicine

Date: 2011

Summary:

This paper is a MUST READ for rehabilitation and training professionals working in ice hockey, especially those of you in the “show”. As you know, Dr. Marc Philippon is one of the world’s leading hip surgeons and like the physician you refer your athletes with problematic hip injuries to. Published in AJSM, this paper looked identified the most appropriate EARLY postoperative hip exercises following hip surgery. With consideration of the fact that the Iliopsoas tendon occasionally becomes irritated or inflamed with early rehabilitation, the Dr. Philippon and friends utilized EMG to determine which of 13 exercises were most appropriate and when. To sum up the results, the exercises that demonstrated the highest peak gluteus medius muscle activation were the single-leg bridge, the prone heel squeeze, and the side-lying hip abduction (either performed with internal hip rotation, against a wall, or with external hip rotation). In comparison, the supine hip flexion, side-lying hip abduction with external rotation, and hip clam exercises demonstrated moderate iliopsoas muscle activation. As a result, the exercises with the best ratios (high gluteus medius activity vs low iliopsoas activity) were the prone heel squeeze, single-leg bridge, and the side-lying hip abduction with internal rotation. Please note that all exercises were then classified into their most appropriate phase of rehabilitation: I, II, or III.
What really caught my attention with this study was the lack of discussion pertaining to optimal and controlled muscle activation of the core musculature in general. It is my assumption that proper progression of early rehabilitation will respect optimal core control and integrity and subsequently optimal iliopsoas activity. It is difficult for me to swallow that those professionals adhering to proper progressions and appropriate rehabilitation principles actually elicit unwanted and increased iliopsoas activity. That said, this study must have been warranted and therefore must speak volumes of the rehabilitation protocols currently prescribed.
Overall, I really enjoyed this paper and certainly walked away with a better understanding of EARLY postoperative gluteus medius and hip rehabilitation.

Philippon, M. et al. (2011). Rehabilitation exercise progression for the gluteus medius muscle with consideration for iliopsoas tendinitis. American Journal of Sports Medicine, Vol. 39(8); 1777-1785
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“Variability for Stability” Webinar

jcubos — Tue, 16 Aug 2011 19:51:53 +0000

Just wanted to let everyone know that I will be presenting a webinar at scwebinars.com on August 31, 2011 at 5:00 pm EST.

Objective:

“This presentation will help you integrate and recognize the value of the stability-motor control continuum, and how it is relevant based on the current research, including the work of Hodges and McGill.”

note: this is an affiliate link

Hope to see you there!

*note: it will also be on Sports Rehab Expert as well so if you’re a member, make sure you look out for it.
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this too is an affiliate link

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The Secret to Improving Flexibility

jcubos — Thu, 11 Aug 2011 17:02:47 +0000

Well it’s not a secret but its a really great theory.

“All you need to do…is teach your muscles how to relax into stretch”

And this theory involves training respiratory control when performing flexibility and mobility exercises. Granted you can hammer away at all the manual therapy you want, but in my opinion, achieving increased range of motion long-term is a direct result of motor learning and control. The nervous system is in charge and if it says no, it means no. If it wants to keep the parking brake engaged it will.

But it won’t do justice to simply stretch out every joint complex in our body with optimal breathing patterns. Because Janda and Cook will tell you that you need to be specific with your attack.

So stabilize what needs stabilizing and mobilize what needs mobilizing but make sure that when you do so, you do so with the highest possible respiratory control you can achieve. And once you get it, you move on!

(watch the abdomen of the guy on the left at 1:50)

For more information on achieving respiratory control, make sure you check out my webinar in Muscle Imbalances Revealed – Upper Body.

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